UNITED INDIA INSURANCE CO LTD Vs. SUNIL GUPTA

JUDGEMENT

(1.) The complainant/respondent obtained a mediclaim policy namely Health Insurance Policy-Gold from the petitioner United India Insurance Co. Ltd. for the period from 01-12-2007 to 30-11-2008. Since the complainant was suffering from morbid obesity, diabetes mellitus, etc., his weight being 164.6 kg., he consulted the doctors in Sir Ganga Ram Hospital who advised bariatric surgery to him. On the advice of the doctors he was admitted to the aforesaid hospital on 22-06-2008 and subjected to Laparoscopic Roux-en-y Gastric Bypass surgery, a surgical procedure for treating morbid obesity and was discharged on 26-06-2008. The complainant paid a sum of Rs.1,84,688/- for the aforesaid surgery and related procedures. The complainant, thereafter, submitted a claim to the petitioner company, seeking reimbursement in terms of the mediclaim policy taken by him. Vide letter dated 01-04-2009 the insurance company rejected the claim in terms of clause 4.5(b) of the mediclaim policy taken by the complainant. Being aggrieved from the rejection of his claim the complainant approached the concerned District Forum seeking a direction to the insurance company to pay the aforesaid amount of Rs.1,84,688/- to him along with interest at the rate of 24% per annum. He also sought compensation amounting to Rs.3,00,000/- and cost of litigation amounting to Rs.15,000/-.

(2.) The complaint was opposed by the insurance company primarily on the ground that the treatment taken by the complainant was excluded under clause 4.5(b) of the policy taken by him and, therefore, it had rightly been repudiated by the company.

(3.) Vide its order dated 19-07-2012 the District Forum issued the following direction to the petitioner company: